Midwestern University Chicago College of Pharmacy

Residency/Fellowship Application Form

All application materials must be postmarked by January 5, 2012. These materials include:

§  This application form

§  A letter of intent stating your career goals, areas of interest, and reasons for applying to this program

§  Your curriculum vitae

§  An official transcript sent directly from all Colleges of Pharmacy attended

§  Three letters of recommendation sent directly from your references

§  It is preferred that two recommendations are from clinical preceptors

Please check to indicate to which program you are applying. Please send application materials to the following:

A
PGY1 Program: Pharmacy / B
PGY2 Program:
Critical Care / C
PGY2 Program:
Infectious Diseases Residency / D
PGY2/3 Program:
Infectious Diseases Fellowship
Jill Borchert, PharmD, BCPS, FCCP
Program Director
c/o Cheryl Elder
Midwestern University Chicago College of Pharmacy
555 31st Street
Downers Grove, IL 60515

630-515-7378 / Tudy Hodgman, PharmD, BCPS, FCCM
Program Director
c/o Cheryl Elder
Midwestern University Chicago College of Pharmacy
555 31st Street
Downers Grove, IL 60515

630-515-6961 / Sheila Wang, PharmD, BCPS AQ-ID
Program Director
c/o Cheryl Elder
Midwestern University
Chicago College of Pharmacy
555 31st Street
Downers Grove, IL 60515

630-515-6248 / Marc Scheetz, PharmD, MSc, BCPS AQ-ID
Program Director
c/o Cheryl Elder
Midwestern University
Chicago College of Pharmacy
555 31st Street
Downers Grove, IL 60515

630-515-6116

Print Name:______

All applicants must be enrolled in the ASHP Resident Matching Program if applying to programs A, B or C (www.natmatch.com/ashprmp)

ASHP Resident Matching Number: ______

If you do not yet know your number, please e-mail Ms. Cheryl Elder at once received.

Please check to indicate preferred mailing address and preferred phone number.

Temporary Address Permanent Address

______

______

______

q Phone______q Phone______

E-Mail Address ______

Education and Training

§  College of Pharmacy: ______

§  Residency: No prior residency Yes, program: ______

Names of Individuals Providing Letters of Reference

1.  ______

2.  ______

3.  ______